Tracking and crediting “unique test(s)”

Our goal in this blog series is to provide a forum regarding topics around the upcoming 2021 E/M Guidelines, to encourage community conversation on how the new guidelines might be applied. In our last post we talked about crediting the ordering and review of a test only once.

Considerations for crediting tests in Amount and/or Complexity of Data to be Reviewed and Analyzed > Category 1: Tests and documents section of the MDM grid to determine your E/M services

You may be reading various articles and attending training sessions which have led to the decision to credit “unique test(s)” when ordered during an encounter.

What if additional tests are ordered between encounters?

In this case, tests not credited in the prior encounter can be credited in the subsequent encounter.  To realize these orders, the series of encounters or dates of orders would need to be tracked.

Jill Young, CEMA, CPC, CEDC, CIMC recommends the following. To take credit for reviewing a test ordered between appointments, the easiest way is to show it in your documentation. For example, “Chest xray ordered on January 1, 2021 showed — ” or “Labs reviewed ordered on January 1, 2021 showed.” This dating should prompt any reviewer to look at visit dates and see the orders were in between encounters. Otherwise, you would rely on the reviewer to do the extra work of looking at the series of patient encounters and noting the dates of the last one and comparing it to the date of the test ordered.

Does your practice see a significant amount of test ordering between encounters?

If tests are often ordered between encounters, will your EMR track and highlight these tests to be credited in the next encounter?

When credited towards an E/M service, will it be obvious in the documentation for retrospective audits?

The Amount and/or Complexity of Data to be Reviewed and Analyzed column of the 2021 MDM grid may cause questions as coders and auditors start to apply it to the varied scenarios you see every day. We are hearing these questions from our customers.  

Keep Calm. There will be grey areas.

As several websites are reporting, you will encounter “grey areas” as you implement the 2021 E/M Outpatient coding guidelines in your organization. As with the E/M Guidelines since 1995, the recommendation by compliance experts is to create internal policies based on your interpretation of guidelines, and follow them consistently within your organization.

As stated by the U.S. Department of Health and Human Services Office of Inspector General (OIG), at “… a minimum, comprehensive compliance programs should include…the development and distribution of written standards of conduct, as well as written policies and procedures that promote the [organization’s] commitment to compliance and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals.”

Though the intent of the 2021 E/M Changes was to “reduce administrative burden”, sufficient documentation of the E/M service provided is still relevant. Documenting how you will handle the “grey areas” will help provide consistency and clarity long after the services were provided.

The OIG’s Compliance Program for Individual and Small Group Physician Practices states: “The physician practice written standards and procedures concerning proper coding reflect the current reimbursement principles set forth in applicable statutes, regulations 21 and Federal, State or private payor health care program requirements and should be developed in tandem with coding and billing standards used in the physician practice. Furthermore, written standards and procedures should ensure that coding and billing are based on medical record documentation. Particular attention should be paid to issues of appropriate diagnosis codes and individual Medicare Part B claims (including documentation guidelines for evaluation and management services).22

Let’s learn together.

We hope you’ll share your thoughts with us!

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